How Kamala Harris rebranded Medicare for All
And why advocates of single payer should be concerned about her becoming VP
Thanks for reading Health and Capital. Today’s post is an extremely topical one, and follows yesterday’s veepstakes media blitz. I find most of this discourse exhausting and some of it counterproductive (being as we are in the middle of a plague and a self-inflicted economic depression, which should take precedent over palace intrigue), but the selection of Kamala Harris as VP nominee does bear some reflection on the role she played as a candidate in the 2020 Democratic Primary in muddling the meaning of the term “Medicare for All.” In this post I’m going to look at the policy proposal the Kamala Harris team released in 2019 and compare it against the actual goals of building a federal, universal single payer program. This is a topic we’ve covered frequently on Death Panel; if you like Health and Capital please take a moment to consider becoming a patron of that project.
[Image Description: Joe Biden and Kamala Harris wear black face masks as they enter their first joint appearance together, photographed in front of a large American flag.]
There are many legitimate criticisms to be made of Kamala Harris as a vice presidential pick. While I’m not going to get into them in this post it’s telling that it’s more or less necessary to mention them from the jump, because her prosecutorial record makes her such a weird choice for VP in the middle of a summer of civil unrest aimed explicitly at abolition of the carceral state. (Ignoring this is obviously ideologically coherent to the politics of the Democratic Party, but I digress). These criticisms are very important to highlight, particularly at a time when party aides have done what they can to keep the details of this record out of wikipedia.
But in the hours since the announcement it’s become clear that one thing that also needs to be revisited is Harris’ record on Medicare for All. As I’ll lay out below, this record should worry pretty much anyone who supports single payer or health justice more broadly, and certainly anyone who views electoralism as the limit of the valid pathways to socialism or communism. This is because during the 2020 primary, Kamala Harris did more than almost any other candidate (with the exception of one) to bend and break the meaning of Medicare for All and lay the groundwork for its potential co-optation into a fundamentally different policy.
I’m basing this largely on the details in the Harris campaign’s own Medicare for All proposal released in July 2019, which I’ll explain later in this post. But before getting into specifics, it’s important to be clear what the stakes are here. Kamala Harris doesn’t support single payer, but the rhetorical gymnastics she did over the course of the primary to assert time and again that she supports Medicare for All has allowed both major parties to pretend that she did. For example, today the Washington Post published a short piece on how Biden and Harris will reconcile their positions on healthcare; their account of how the primary played out is something I can only describe as an astonishing work of fiction:
Presumptive presidential nominee Joe Biden and Sen. Kamala Harris (D-Calif.), fought tooth and nail over Medicare-for-all during the primary race.
She slammed him for backing only incremental reforms that would leave some Americans uncovered. He called her Medicare-for-all plan “malarkey” and called it a “have-it-every-which-way approach.”
Now, as running mates, the pair will have to adopt a cohesive consistent message on health-care. And that means Harris must move to her political right on the subject.
That Harris supported Medicare for All is also being reproduced on the right as an attack line (perhaps predictably; after all, conservatives even call Joe Biden a socialist).
[Image Description: Screenshot of Breitbart article headlined “Kamala Harris: Most Liveral Senator; Backed Green New Deal, ‘Medicare For All’”]
Obviously this is all going to make for some very stupid and short-lived arguments. You can already see a preponderance of conservatives’ attack lines being met with this link to a Newsweek article headlined “Kamala Harris No Longer Supports Bernie Sanders’ Medicare for All Plan.” But you also see a lot of people who are very excited about Kamala Harris as the VP pick touting her as a supporter of Medicare for All and thus conjuring her some kind of imaginary progressive bona fides. So in some sense, what I want to make sure to do here is establish the following: (1) Kamala Harris doesn’t support Medicare for All, and anyone who tells you otherwise is incorrect; (2) the details of the plan the Harris campaign released that was called “Medicare for All” are a disqualifying co-optation that should frankly make anyone suspicious of her entire political career.
The Primary, In Brief
Over the course of the primary Harris took a number of different positions on Medicare for All, the back-and-forth of which is mostly neither particularly interesting or relevant. In sum, Harris entered the primary having been an original co-sponsor of the 2017 version of the Sanders Medicare for All bill (a version which, notably, did not yet include long-term care). This is how Harris was messaging on single payer in February of 2019, mere weeks before the release of the Jayapal bill:
By April, the Sanders team released their updated version of the bill (including long-term care for the first time, among other improvements). Harris cosponsored the bill and even ran ads that month highlighting her support.
Notably though, by this time Harris had already tipped her hand that establishing a single payer system in the United States wasn’t really a priority. In January 2019, Harris very publicly walked back comments she made in a CNN town hall in support of replacing all private health insurance with a single payer system. This was repeated in June, after Harris raised her hand in response to a debate question “Who here would abolish their private health insurance in favor of a government run plan?” Within hours she rushed to walk it back, telling NBC:
“Medicare for All — in my vision of Medicare for All, it includes private insurance where people can have supplemental insurance.”
[Image Description: Screenshot from 27 June 2019 Democratic Primary debate. Bernie Sanders (left) and Kamala Harris (right) each raise their hands when asked “Many people watching at home have health insurance through their employer. Who here would abolish their private health insurance in favorite of a government-run plan?”]
It’s worth pausing to explain why this answer doesn’t even make sense. The goal of Medicare for All—and both the Sanders and Jayapal bills that share the name—is explicitly to replace all private health insurance with a federal universal single payer. Doing so produces a number of beneficial effects, whereas including a role for private insurance companies both prevents those beneficial effects from happening and preserves parts of our health insurance system that are actively deleterious.
One big reason for this is the immense amount of administrative apparatus healthcare providers currently need just to deal with billing insurance companies. This is because each private insurance company has its own criteria, its own lists of drugs and procedures it covers and doesn’t cover (known as a formulary), and usually has different formularies for different tiers of coverage.
Beyond that, insurers make money primarily through paying out less than they take in from premiums—in other words, by denying insurance claims—which creates incentives for them to try and make it as difficult as possible both for people (patients) and providers to successfully file a claim. Studies by Steffie Woolhandler and David Himmelstein have shown that physicians spend at least one sixth of their time on such administrative tasks, and that a full third (34.2%) of all healthcare spending in the United States goes to administrative spending.
(For a vivid account of how absurd this system is, I recommend Death Panel’s interview from earlier this year with Vivian Negron, who has worked in medical billing on the provider side for almost 40 years).
Replacing these hurdles—and the role of the insurance company as a middleman between a person and their care—would have obvious positive effects on the entire healthcare system. Preserving a role for private insurance companies, however, does nothing to remove this problem. Insurers’ entire business model is to extract profit by limiting or denying needed care, so no matter how much you try to reform or regulate them they will remain, fundamentally, an exploitative industry carrying out a set of endless, redundant, meaningless and ultimately harmful tasks. In the worst case—as people point out to critique the limits of the public option—this not only preserves the system, but adds another formulary on top of an already convoluted system.
The arguments supporting this are numerous and to list them would require the remainder of this post. I would suggest listening to the Medicare for All Week series we produced as Death Panel in February, or reading something like this piece from Libby Watson.
Medicare (Advantage) For All
By the end of July 2019, the Kamala Harris campaign had released their own separate proposal for Medicare for All, the first definitive move in the primary to swap in a fundamentally different policy proposal under the same name as the popular single payer bill. Even Pete Buttigieg had not been brazen enough to attempt to fully co-opt the term, choosing (absurdly) to call his own healthcare policy “Medicare for All Who Want It.” The details of the Harris plan were laughable but achieved the basics in the eyes of the press: technically speaking the plan detailed a process of eventually, over the course of ten entire years, making a form of Medicare available to everyone. This allowed her to proclaim support for “Medicare for All” while actually meaning something altogether different.
This document was a little light on detail (it was, after all, in 2020 Democratic primary style, a Medium post), but offers enough to see exactly the framework the Harris policy team had in mind. The following is the key segment:
Third, in setting up this plan, we will allow private insurers to offer Medicare plans as a part of this system that adhere to strict Medicare requirements on costs and benefits. This would function similar to how private Medicare plans work today, which cover about a third of Medicare seniors, and operate within the Medicare system.
As mentioned above, the plan would make a form of Medicare available to everyone eventually—but this just so happens to be the worst form imaginable. The Medicare plans offered by private insurers they’re mentioning here are what’s known as Medicare Advantage plans; this is privatized Medicare, and the plans are miserable. That they are miserable shouldn’t be in itself surprising, as on the whole privatized social services or welfare benefits are a sign of trouble and exploitation, but if you want a slightly more technical breakdown Tim Faust wrote a very good one that later appeared in an expanded form in his book. Medicare Advantage plans are essentially the regular health insurance companies you know and hate, operating under the Medicare brand and doing everything they can to make sure they can get as much federal funding as possible, even if it means committing fraud to get more money for each person covered, as many have done. Compared to traditional Medicare, being covered by a Medicare Advantage plan is much more similar to dealing with a regular health insurance company, because it basically is a plan from a regular health insurance company.
As a result, Medicare Advantage plans are both extremely profitable for the companies that offer them, and aren’t very effective for much else. In fact, becoming ill was found by the Government Accountability Office (GAO) to be an indicator that you will be “substantially more likely” to switch off of a Medicare Advantage plan and onto a different form of Medicare. In other words, people tend to switch off of these health insurance plans as soon as they become ill and, you know, have to actually use them.
It should come as no surprise that conservatives absolutely love these plans, to the point that the current head of the Centers for Medicare & Medicaid Services (CMS) actively promotes them over traditional Medicare:
Further details in the Harris plan come up just as short, making the entire document amount to little more than a rebranding exercise for our concept of what single payer should be, or could do. Libby Watson detailed many of these in a piece for Splinter just after it was first released:
There are some key details missing from Harris’ plan, too. She says there will be no deductibles or co-pays, but doesn’t mention whether there will be premiums. She says the plan will have “strong caps on out-of-pocket costs,” but doesn’t say what that would be, or what out-of-pocket costs would remain. And on drug costs, one of the biggest areas of spending for seniors under the current Medicare plan, she only says that she will “empower the Secretary of Health to negotiate for lower prescription drug prices” and perform “a serious auditing of prescription drug costs to ensure Americans aren’t paying more for their prescription drugs than other comparable countries.” Sanders’ plan, by contrast, limits individual drug cost-sharing to $200 per year, or $17 per month.
In their write-up of Harris’ plan, the New York Times wrote that the preservation of private Medicare plans “could go a long way toward neutralizing fierce opposition from insurance companies.” This is laughable. Even Biden’s plan, a pathetic public option, was attacked by the healthcare industry’s anti-Medicare for All group.
Clearly these are proposals for modest reforms, and not particularly good ones. But all of this points to the biggest issue here: depending on the outcome of the election, we may end up with a near-term future in which Harris is either delegated a policy role as vice president, or eventually becomes president. Considering this, it will be very important to remember that rather than outright saying she did not support single payer during the primary Harris chose to carry it as a slogan, asserting all along that she was for Medicare for All—going so far as to release a document that contradicts the entire idea of single payer while addressing none of the material demands the movement reflects.
This isn’t just theoretical. The actions of Harris and others muddied the broader messaging on single payer during the primary, and as a result has made a pathway to some neoliberal re-imagination and co-optation of Medicare for All much more legible. There’s already a subset of conservatives at work on normalizing the idea, as exemplified by a recent opinion in JAMA Health Forum by Stuart M. Butler, a conservative Brookings Institution fellow who also favors legislation that would defund social security. In an opinion piece called “Medicare Advantage for All, Perhaps?” Butler writes:
Medicare Advantage for all could be a good starting point for a bipartisan discussion on creating a new framework for the US health system. … [it] would involve contentious debate. But to reach eventual agreement on big changes in society, it is necessary to have a framework in mind that is likely to command broad support and that the current system could evolve toward with minimum disruption. Medicare Advantage for all is such a framework. Medicare for all is not.
If Harris becomes the vice president, it’s incumbent on us to make sure the stage is not set for Democrats and Republicans to make a spectacle of arriving at an agreement to pass Medicare Advantage for All under the guise of “Medicare for All.” The profits these companies extract are quite literally people’s lives. Politicians that would rebrand a people’s movement in order to protect those profits are worse than those insurers themselves.
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